If you are new to our office, we ask that you fill out these forms prior to your visit. We have made these forms easy to complete online, and at the end you will click the “Submit” button and we will receive the forms in an encrypted secure email.

During your first visit you will likely have your eyes dilated. This means your eyes will be light sensitive, so please bring a pair of sunglasses for your drive home. If you don’t have sunglasses, we will provide sun wraps for you. When your eyes are dilated you will still be able to drive, but your reading vision will be blurry for a few hours.

Step 1 of 4 – Patient Information

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Patient Information

Name*

FirstLast

Date of Birth*

Sex*

Male

Female

Address*

Street AddressAddress Line 2CityStateZIP Code

Home Phone*

Cell Phone

Work Phone

Email*

Marital Status*

Emergency Contact Name*

FirstLast

Emergency Contact Phone Number*

Employer*

Primary Care Physician*

FirstLast

Primary Care Physician Phone Number*

Referring Physician Name

FirstLast

Referring Physician Phone

How did you hear about us?

The following information is required by the government Patient Protection and Affordable Care Act of 2010.

Race*

White

Black or African American

Asian

American Indian/Alaska Native

Native Hawaiian or Other Pacific Islander

More than one race

Wish not to report

Ethnicity*

Not Hispanic or Latino

Hispanic or Latino

Wish not to report

Language

English

Insurance Information:

Primary Medical Insurance*

Contract Number*

Subscriber's Name*

FirstLast

Subscriber's Date of Birth*

Secondary Medical Insurance

Contract Number

Subscriber's Name

FirstLast

Subscriber's Date of Birth

Medical Information

Do you have an immediate family history of: Cataracts / Glaucoma / Macular Degeneration*

NOTICE OF PRIVACY PRACTICES COMPLETE EYE CARE

You must accept or decline this Privacy Policy to continue filling out your information for an appointment:

I give permission for the following people to have unlimited access to my medical records, appointment information, & billing information at Complete Eye Care. I understand the following people will be able to make and cancel appointments for me, discuss billing questions and my medical information with the staff of Complete Eye Care.

No I do not want to give my permission for anyone to have access to my medical records.

I also understand that at any time I can add or delete names on this list by notifying Complete Eye Care in writing. Furthermore, anyone that I request to be deleted will no longer have access to any of my Personal Health Information.

Contact #1

Name

Relationship

Phone Number

Contact #2

Name

Relationship

Phone Number

Contact #3

Name

Relationship

Phone Number

Payment Responsibility

I request payment of insurance benefits for services provided to me by Complete Eye Care, its medical staff and affiliated physicians and organizations, be made to Complete Eye Care. I understand and agree to pay for the services rendered to me that are not covered by my insurance or paid directly to Complete Eye Care, including co-payments and deductibles. I agree to forward to Complete Eye Care any insurance payments and the explanation of benefits sent to me for these services.